Diagnoses
SOAP Notes
Secondary symptoms
Diagnoses 2
Random
100
Decreased range of motion, muscle wasting, memory deficits, anxiety

COVID-19 recovered

100

This portion of a SOAP note clarifies the future goals and any modifications that will be used with the patient

Plan

100
Pain, inactivity, complications from inactivity & bed rest

Guillain-Barre Syndrome

100

a condition that makes it difficult to breathe

(COPD) Chronic Obstructive Pulmonary Disease

100

3 common diagnoses in acute inpatient rehab

stroke, COVID recovery, amputation, heart surgery, MVA

200

aphasia, visual neglect, depression, confusion, depression, one-sided weakness

Glioblastoma

200

Subjective, Objective, Assessment, Plan

4 parts of a SOAP note

200

Ringing in ears, dizziness, communication issues

Hearing loss

200

a complex disease that occurs when insulin production is too low or lacking entirely

Diabetes

200

5 Domains of Well-Being

Physical

Social

Cognitive

Emotional

Spiritual

300

disorder of the heart and blood vessels

Cardiovascular

300

Includes a direct quote from the patient

Subjective

300

muscle atrophy, cardiopulmonary endurance issues, upper and lower extremity weakness

osteoarthritis

300

causes abnormal signals in the brain; can cause a brief surge of electrical activity that affects the brain

Epilepsy

300

3 examples of physical domain areas of focus for Therapeutic Recreation

gross motor skills, fine motor skills, balance, sitting tolerance, standing tolerance

400
Hip and knee replacements, hip fractures, bone or joints

Orthopedic conditions

400

Is composed of the therapists interpretation of both the patient's direction comments and behaviors/participation during the TR intervention or program

Assessment

400
Confinement to a wheelchair, inadequate nutrition or illness with decreased mobility can be the cause of this

Pressure Ulcer

400

Two types of COPD that interfere with normal lung function

Chronic bronchitis and Emphysema

400

3 TR interventions used for patients who had a stroke

Connect 4, Checkers, Chess, Guess Who, Name 5, Relaxation, Yoga

500

overall decline in functional status characterized by difficulty walking, decline in ADL's and decreased energy

Debility

500

Detailed description of the patient's behavior and participation during the TR intervention or program

Observation

500

hypoglycemia, hyperglycemia, dental issues, blindness, amputations

Diabetes

500

a form of soft tissue rheumatism in adults

Fibromyalgia

500

3 TR interventions for patients who have behavioral issues

music

relaxation

card games

word searches

validation